How to Document
Hernia using ICD-10 Codes
Hernia is a common problem that causes a localized bulge in the abdomen or groin. ICD-10 codes used for documenting various types of this disorder are www.outsourcestrategies.com discussed in this article.
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Hernia is a common problem that usually develops when an internal part of the body pushes through an opening in the muscle or surrounding tissue wall. In most cases, this condition involves a very few symptoms and causes a swelling or localized bulge in the abdomen or groin. Documenting this condition correctly requires
considering
several
important
aspects.
For
accurate
clinical
documentation of this disorder, physicians can opt for medical billing outsourcing services. Generally, most hernias occur within the abdominal cavity, between the chest and the hips. On the other hand, they can also appear in the upper thigh, belly button, and groin areas. This condition is usually caused by a combination of muscle weakness and strain. At times, the muscle weakness may be present at birth, but more often it occurs later in life. In short, anything that causes an increase in abdominal pressure (including obesity, lifting heavy objects, diarrhea or constipation, or persistent coughing or sneezing) can result in hernia. Depending on its specific causes, a hernia can develop quickly or over a long period of time. Hernias aren’t immediately life-threatening, but they don’t go away on their own. Treatment options include corrective surgery - either via an open or keyhole operation, to prevent potentially dangerous complications. Common Hernia Types The most common types of hernia are –
Inguinal hernia - occurs in the inner groin
Ventral - occurs in the general abdominal/ventral wall
Umbilical - occurs at the belly button
Incisional - occurs through an incision or scar in the abdomen
Hiatal - occurs inside the abdomen, along the upper stomach/diaphragm
Femoral hernia - occurs in the upper thigh/outer groin
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Signs and Symptoms One of the most common symptoms of a hernia is a bulge or lump in the affected area. Other common symptoms include –
Swelling or bulge in the groin or scrotum (the pouch that contains the testicles)
Increased pain or discomfort in the affected area (usually the lower abdomen), especially when bending over, coughing, or lifting
Increase in the bulge size over time
A dull aching sensation
A sense of feeling full or signs of bowel obstruction
Diagnosing and Coding Hernia Hernias are usually diagnosed through a detailed physical examination. Physicians may check or feel for a bulge in the abdomen or groin area that gets larger when the patient stands, coughs or strains. If the diagnosis isn’t readily apparent, physicians may conduct various imaging studies/tests such as an abdominal ultrasound, CT scan or MRI scan. If a hernia is relatively small and is not affecting a patient, physicians may recommend watchful waiting. For instance, in children, physicians may try applying manual pressure to reduce the bulge before considering a surgical option. Painful or enlarged hernias require surgery to relieve discomfort and prevent further complications. Surgery involves an open hernia repair and laparoscopic repair. ICD-10 Codes to Use General Surgery medical coding involves using the specific ICD-10 diagnosis codes for reporting hernia on your medical claims. ICD-10-CM codes used to indicate a diagnosis of hernia come in the rangeK40 - K46.
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K40 - Inguinal hernia
K40.0 - Bilateral inguinal hernia, with obstruction, without gangrene
K40.00 - Bilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent
K40.01 - Bilateral inguinal hernia, with obstruction, without gangrene, recurrent
K40.1 - Bilateral inguinal hernia, with gangrene
K40.10 - Bilateral inguinal hernia, with gangrene, not specified as recurrent
K40.11 - Bilateral inguinal hernia, with gangrene, recurrent
K40.2 - Bilateral inguinal hernia, without obstruction or gangrene
K40.20 - Bilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent
K40.21 - Bilateral inguinal hernia, without obstruction or gangrene, recurrent
K40.3 - Unilateral inguinal hernia, with obstruction, without gangrene
K40.30 - Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent
K40.31 - Unilateral inguinal hernia, with obstruction, without gangrene, recurrent
K40.4 - Unilateral inguinal hernia, with gangrene
K40.40 - Unilateral inguinal hernia, with gangrene, not specified as recurrent
K40.41 - Unilateral inguinal hernia, with gangrene, recurrent
K40.9
-
Unilateral
inguinal
hernia,
without
obstruction
or
gangrene
K40.90 - Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent
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K40.91 - Unilateral inguinal hernia, without obstruction or gangrene, recurrent
K41 - Femoral hernia
K41.0
-
Bilateral
femoral
hernia,
with
obstruction,
without
gangrene
K41.00 - Bilateral femoral hernia, with obstruction, without gangrene, not specified as recurrent
K41.01 - Bilateral femoral hernia, with obstruction, without gangrene, recurrent
K41.1 - Bilateral femoral hernia, with gangrene
K41.10 - Bilateral femoral hernia, with gangrene, not specified as recurrent
K41.11 - Bilateral femoral hernia, with gangrene, recurrent
K41.2 - Bilateral femoral hernia, without obstruction or gangrene
K41.20 - Bilateral femoral hernia, without obstruction or gangrene, not specified as recurrent
K41.21 - Bilateral femoral hernia, without obstruction or gangrene, recurrent
K41.3 - Unilateral femoral hernia, with obstruction, without gangrene
K41.30 - Unilateral femoral hernia, with obstruction, without gangrene, not specified as recurrent
K41.31 - Unilateral femoral hernia, with obstruction, without gangrene, recurrent
K41.4 - Unilateral femoral hernia, with gangrene
K41.40 - Unilateral femoral hernia, with gangrene, not specified as recurrent
K41.41 - Unilateral femoral hernia, with gangrene, recurrent
K41.9 - Unilateral femoral hernia, without obstruction or gangrene
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K41.90 - Unilateral femoral hernia, without obstruction or gangrene, not specified as recurrent
K41.91 - Unilateral femoral hernia, without obstruction or gangrene, recurrent
K42 - Umbilical hernia
K42.0 - Umbilical hernia with obstruction, without gangrene
K42.1 - Umbilical hernia with gangrene
K42.9 - Umbilical hernia without obstruction or gangrene
K43 - Ventral hernia
K43.0 - Incisional hernia with obstruction, without gangrene
K43.1 - Incisional hernia with gangrene
K43.2 - Incisional hernia without obstruction or gangrene
K43.3 - Parastomal hernia with obstruction, without gangrene
K43.4 - Parastomal hernia with gangrene
K43.5 - Parastomal hernia without obstruction or gangrene
K43.6 - Other and unspecified ventral hernia with obstruction, without gangrene
K43.7 - Other and unspecified ventral hernia with gangrene
K43.9 - Ventral hernia without obstruction or gangrene
K44 - Diaphragmatic hernia
K44.0 - Diaphragmatic hernia with obstruction, without gangrene
K44.1 - Diaphragmatic hernia with gangrene
K44.9 - Diaphragmatic hernia without obstruction or gangrene
K45 - Other abdominal hernia
K45.0 - Other specified abdominal hernia with obstruction, without gangrene
K45.1 - Other specified abdominal hernia with gangrene
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K45.8 - Other specified abdominal hernia without obstruction or gangrene
K46 - Unspecified abdominal hernia
K46.0 - Unspecified abdominal hernia with obstruction, without gangrene
K46.1 - Unspecified abdominal hernia with gangrene
K46.9 - Unspecified abdominal hernia without obstruction or gangrene
Medical coding for different types of hernia can be a tricky process. For accurate and timely medical billing and claims submission, surgical practices can outsource their medical coding tasks to a professional medical billing company that provides the services of AAPC-certified coding specialists. According to reports from Medscape.com, more than 1 million abdominal wall hernia repairs are performed each year in the United States (2017 statistics), with inguinal hernia repairs constituting nearly 770,000 of these cases. Recognizing the early symptoms of hernia helps to mitigate the risk factors associated with this condition. Hernia, if left untreated may grow and become more painful causing severe complications like strangulation. Prevention tips include – quitting the habit of smoking, maintaining a healthy body weight, avoiding straining during bowel movements or urination, and avoiding lifting weights that are too heavy.
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